"Man kan bli bättre om man vet vad bättre är!" : En studie kring effektivitetsbegreppet som en samhällelig grundbult

Sammanfattning: The study takes as its starting point the far-reaching organizational changes that have occurred within the public sector in Sweden, particularly the public health care sector, during the last decade. The aim of achieving efficacy has been an important driving force in these processes, which often concern mergers or reductions in personnel that are regarded as a route to success. Paradoxically, Swedish and international research has suggested only a small part of the organizational changes of this sort to lead to the results that are striven for. This highly unsatisfactory situation, with its deleterious effects on the economy and on conditions of working life, is of central concern here. The problematical character of the efficacy concept as used in a modernistic context is emphasized. Models proposed earlier for defining efficacy in mathematical terms as well as other definitions of too narrow a character are questioned. The study proposes that by examining the concept from a critical, postmodernist point of view an important broadening of the efficacy concept and of its implications in the public health care sector can be achieved. One aims of the study is to elucidate the complexity of efficacy as a social construction, highlighting both the dominant role it can play in a society and, somewhat paradoxically, its highly relativistic nature from both a historical and a social standpoint. Another aim is to develop a theoretically and pragmatically relevant method for implementing change and effectiveness in politically steered organizations as seen from a postmodern perspective. A practical point of departure for the thesis project was the merger of two surgical clinics in southern Sweden that had been decided upon at a political level. Three methodological approaches were taken. One involved giving questionnaires to all persons employed at the clinics in question (n=347). Another approach was to study the construction of the efficacy concept within the organization through forming a group of political representatives, health care administrators and health care personnel (n=12) whose discussions of basic issues were studied by use of the Diary-in-group method. The third approach was to use the Repertory Grid Technique as a pre- and posttest method for examining changes in patterns of thinking that had occurred. It was found that strong criticism was directed against the political level in the organization, especially in connection with the merger of the clinics, reflective of the problems connected with such a move. Efficacy as it was understood appeared to be a highly complex, individually differing and "non-objective" concept. The results achieved in the Diary-in-group sessions could be viewed as very positive in the sense of a more differentiated conception of efficacy being arrived at, suggesting the constructive effects of discussing complex issues of this sort within an organization. There were also found to be many different levels of discourse which affect the efficacy process of an organization, some of them far removed from the organization itself.